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Fan Y, Wu M, Li X, Zhao J, Shi J, Ding L, Jiang H, Li Z, Zhang W, Ma T, Wang D, Ma L. Potassium levels and the risk of all-cause and cardiovascular mortality among patients with cardiovascular diseases: a meta-analysis of cohort studies. Nutr J 2024; 23:8. [PMID: 38195532 PMCID: PMC10777575 DOI: 10.1186/s12937-023-00888-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/30/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND Abnormal blood potassium levels are associated with an increased risk of cardiometabolic diseases and mortality in the general population; however, evidence regarding the association between dyskalemia and mortality among patients with cardiovascular disease (CVD) remains inconclusive. This study aimed to evaluate the association of potassium levels with all-cause and cardiovascular mortality among patients with CVD. METHODS PubMed, Embase, Web of Science, and Cochrane Library databases were searched up to August 2023 to identify relevant cohort studies among patients with CVD, such as myocardial infarction, stroke, and heart failure. Abnormal potassium levels were considered as hypokalemia or hyperkalemia. The primary outcomes were all-cause mortality based on follow-up length (including in-hospital, short-term and long-term mortality) and cardiovascular mortality. The methodological quality of included studies was assessed by using the Newcastle-Ottawa Scale. The pooled relative risks (RRs) and 95% confidence intervals (CIs) were calculated using random-effects models. Restricted cubic splines were applied to explore the dose-response relationship. RESULTS Thirty-one cohort studies involving 227,645 participants with an average age of 68.3 years were included in the meta-analysis, all of which achieved moderate to high quality. Hyperkalemia was significantly associated with an approximately 3.0-fold increased risk of all-cause in-hospital mortality (RR:2.78,95CI%:1.92,4.03), 1.8-fold of all-cause short-term mortality (RR:1.80, 95CI%:1.44,2.27), 1.3-fold of all-cause long-term mortality (RR:1.33, 95CI%:1.19,1.48) and 1.2-fold of cardiovascular mortality (RR:1.19, 95CI%:1.04,1.36). Similar positive associations were also observed between hypokalemia and risk of all-cause mortality and cardiovascular mortality. The RRs of all-cause in-hospital, short-term, long-term mortality and cardiovascular mortality with hyperkalemia were attenuated to 2.21 (95CI%:1.60,3.06), 1.46(95CI%:1.25,1.71), 1.23 (95CI%:1.09,1.39) and 1.13 (95CI%:1.00,1.27) when treating hypokalemia together with normokalemia as the reference group. A U-shaped association was observed between potassium levels and mortality, with the lowest risk at around 4.2 mmol/L. CONCLUSIONS Both hypokalemia and hyperkalemia were positively associated with the risk of mortality in patients with CVD. Our results support the importance of potassium homeostasis for improving the CVD management. REGISTRATION PROSPERO, CRD42022324337.
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Affiliation(s)
- Yahui Fan
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, China
| | - Min Wu
- The First Affiliated Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, China
| | - Xiaohui Li
- Department of Maternal and Child Health Management, Sichuan Provincial Maternity and Child Health Care Hospital, Chengdu, 610045, China
| | - Jinping Zhao
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, China
| | - Jia Shi
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, China
| | - Lu Ding
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, China
| | - Hong Jiang
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, China
| | - Zhaofang Li
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, China
| | - Wei Zhang
- The First Affiliated Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, China
| | - Tianyou Ma
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, China.
- Key Laboratory for Disease Prevention and Control and Health Promotion of Shaanxi Province, Xi'an, 710061, China.
- Key Laboratory of Environment and Genes Related to Diseases (Xi'an Jiaotong University), Ministry of Education of China, Xi'an, 710061, China.
| | - Duolao Wang
- Guangdong Key Laboratory of Age-Related Cardiac and Cerebral Diseases, Affiliated Hospital of Guangdong Medical University, Zhanjiang, 524013, China.
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK.
| | - Le Ma
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, China.
- Key Laboratory for Disease Prevention and Control and Health Promotion of Shaanxi Province, Xi'an, 710061, China.
- Key Laboratory of Environment and Genes Related to Diseases (Xi'an Jiaotong University), Ministry of Education of China, Xi'an, 710061, China.
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Li J, Yu H, Cui L, Song H, Chu Y, Dong S. The ratio of QRS/RV 6-V 1: a new electrocardiographic predictor of short- and long-term adverse clinical outcomes in patients with acute myocardial infarction combined with new-onset right bundle branch block. Front Cardiovasc Med 2023; 10:1129235. [PMID: 37324640 PMCID: PMC10267865 DOI: 10.3389/fcvm.2023.1129235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 04/24/2023] [Indexed: 06/17/2023] Open
Abstract
Background A few studies have focused on electrocardiography (ECG) parameters correlating with clinical prognosis in patients with acute myocardial infarction (AMI) combined with new-onset right bundle branch block (RBBB). Objective To assess the prognostic value of a new ECG parameter, namely, the ratio of QRS duration/RV6-V1 interval (QRS/RV6-V1), in patients with AMI combined with new-onset RBBB. Materials and methods A total of 272 AMI patients combined with new-onset RBBB who received primary percutaneous coronary intervention (P-PCI) were retrospectively enrolled in the study. First, the patients were divided into survival group and non-survival group. Demographic, angiographic, and ECG characteristics were compared between the two groups. Receiver operating characteristic (ROC) curve was used to screen the best ECG parameter for predicting 1-year mortality. Second, the ratio of QRS/RV6-V1, a continuous variable, was converted to the high ratio group and low ratio group according to the optimal cutoff value point determined by the X-tile software. We compared the patient's demographic, angiographic, and ECG characteristics, in-hospital major adverse cardiovascular events (MACE), and 1-year mortality between the two groups. Multivariate logistic and Cox regressions were used to evaluate whether the ratio of QRS/RV6-V1 was an independent prognostic factor of in-hospital MACE and 1-year mortality. Results The ROC curve showed that the ratio of QRS/RV6-V1 had a higher value for predicting in-hospital MACE and 1-year mortality than the QRS duration, RV6-V1 interval, and RV1 interval. The patients in the high ratio group had significantly higher CK-MB peak and Killip class, lower ejection fraction (EF%), higher ratio of the left anterior (LAD) descending artery as infarct-related artery (IRA), and longer total ischemia time (TIT) than those in the low ratio group. The QRS duration was wider in the high ratio group than that in the low ratio group, whereas RV6-V1 was narrower in the high ratio group compared with that in the low ratio group. The in-hospital MACE rate (93.3% vs. 31.0%, p < 0.001) and 1-year mortality rate (86.7% vs. 13.2%, p < 0.001) in the high ratio group were higher than those in the low ratio group. The higher ratio of QRS/RV6-V1 was an independent predictor of in-hospital MACE (odds ratio, 8.55; 95% CI, 1.40-52.37; p = 0.02) after adjusting other confounders. Cox regression showed that the higher ratio of QRS/RV6-V1 predicted higher 1-year mortality of the patients with AMI combined with new-onset RBBB [hazard ratios (HR), 12.4; 95% CI, 7.26-21.22); p < 0.001] than the lower ratio of QRS/RV6-V1, and the HR still stayed at 2.21 even after a multivariable adjustment (HR, 2.21; 95% CI, 1.05-4.64); p = 0.037). Conclusion According to the results of our study, the high ratio of QRS/RV6-V1 (>3.0) was a valuable predictor of short- and long-term adverse clinical outcomes in AMI patients combined with new-onset RBBB. The implications of the high ratio of QRS/RV6-V1 were severe ischemia and pseudo synchronization between bi-ventricle.
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Affiliation(s)
- Jingchao Li
- Department of Cardiology, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Haijia Yu
- Department of Emergency, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Luqian Cui
- Department of Cardiac Care Unit, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Huihui Song
- Department of Emergency, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Yingjie Chu
- Department of Cardiology, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Shujuan Dong
- Department of Cardiology, Henan Provincial People’s Hospital, Zhengzhou, China
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Patel AK, Gai J, Trujillo-Rivera E, Faruqe F, Kim D, Bost JE, Pollack MM. National Intravenous Acetaminophen Use in Pediatric Inpatients From 2011–2016. J Pediatr Pharmacol Ther 2022; 27:358-365. [DOI: 10.5863/1551-6776-27.4.358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 04/17/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE
To 1) determine current intravenous (IV) acetaminophen use in pediatric inpatients; and 2) determine the association between opioid medication duration when used with or without IV acetaminophen.
METHODS
A retrospective analysis of pediatric inpatients exposed to IV acetaminophen from January 2011 to June 2016, using the national database Health Facts.
RESULTS
Eighteen thousand one hundred ninety-seven (2.0%) of 893,293 pediatric inpatients received IV acetaminophen for a median of 14 doses per patient (IQR, 8–56). A greater proportion of IV acetaminophen patients were admitted to the intensive care unit (ICU) (14.8% vs 5.1%, p < 0.0001), received positive pressure ventilation (2.0% vs 1.5%, p < 0.0001), had a higher hospital mortality rate (0.9% vs 0.3%, p < 0.0001), and were operative (35.5% vs 12.8%, p < 0.001) than those not receiving IV acetaminophen. The most common operations associated with IV acetaminophen use were musculoskeletal and digestive system operations. Prescription of IV acetaminophen increased over time, both in prescription rates and number of per patient doses. Of the 18,197 patients prescribed IV acetaminophen, 16,241 (89.2%) also were prescribed opioids during their hospitalization. A multivariate analysis revealed patients prescribed both IV acetaminophen and opioids had a 54.8% increase in opioid duration as compared with patients who received opioids alone.
CONCLUSIONS
This is the first study to assess IV acetaminophen prescription practices for pediatric inpatients. Intravenous acetaminophen prescription was greater in the non-operative pediatric inpatient population than operative patients. Intravenous acetaminophen prescription was associated with an increase in opioid duration as compared with patients who received opioids alone, suggesting that it is commonly used to supplement opioids for pain relief.
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Affiliation(s)
- Anita K. Patel
- Department of Pediatrics, Division of Critical Care Medicine DC (AKP, MMP), Children's National Health System, Washington, DC
- George Washington University School of Medicine and Health Sciences (AKP, MMP, JG, ET-R, DK, JEB), Washington, DC
| | - Jiaxiang Gai
- Children's National Health System (JG, FF, DK, JEB), Washington, DC
- George Washington University School of Medicine and Health Sciences (AKP, MMP, JG, ET-R, DK, JEB), Washington, DC
| | - Eduardo Trujillo-Rivera
- Department of Pediatrics, Division of Critical Care Medicine DC (AKP, MMP), Children's National Health System, Washington, DC
- George Washington University School of Medicine and Health Sciences (AKP, MMP, JG, ET-R, DK, JEB), Washington, DC
| | - Farhana Faruqe
- Children's National Health System (JG, FF, DK, JEB), Washington, DC
| | - Dongkyu Kim
- Children's National Health System (JG, FF, DK, JEB), Washington, DC
- George Washington University School of Medicine and Health Sciences (AKP, MMP, JG, ET-R, DK, JEB), Washington, DC
| | - James E. Bost
- Children's National Health System (JG, FF, DK, JEB), Washington, DC
- George Washington University School of Medicine and Health Sciences (AKP, MMP, JG, ET-R, DK, JEB), Washington, DC
| | - Murray M. Pollack
- Department of Pediatrics, Division of Critical Care Medicine DC (AKP, MMP), Children's National Health System, Washington, DC
- George Washington University School of Medicine and Health Sciences (AKP, MMP, JG, ET-R, DK, JEB), Washington, DC
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Patel AK, Gai J, Trujillo-Rivera E, Faruqe F, Kim D, Bost JE, Pollack MM. Association of Intravenous Acetaminophen Administration With the Duration of Intravenous Opioid Use Among Hospitalized Pediatric Patients. JAMA Netw Open 2021; 4:e2138420. [PMID: 34932106 PMCID: PMC8693214 DOI: 10.1001/jamanetworkopen.2021.38420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 10/17/2021] [Indexed: 11/14/2022] Open
Abstract
Importance Adoption of multimodal pain regimens that incorporate nonopioid analgesic medications to reduce inpatient opioid administration can prevent serious opioid-related adverse effects in children, including tolerance, withdrawal, delirium, and respiratory depression. Intravenous (IV) acetaminophen is in widespread pediatric use; however, its effectiveness as an opioid-sparing agent has not been evaluated in general pediatric inpatients. Objective To determine if IV acetaminophen administered prior to IV opioids is associated with a reduction in the total duration of IV opioids administered compared with IV opioids administered without IV acetaminophen in general pediatric inpatients. Design, Setting, and Participants This comparative effectiveness research study included data on pediatric inpatients from 274 US hospitals between January 2011 and June 2016 collected from a national database. Outcomes were compared with a propensity score-matched analysis of pediatric inpatients administered IV opioids without IV acetaminophen (control) and those administered IV acetaminophen prior to IV opioids (intervention). Data were analyzed from January 2020 through October 2021. Exposures Patients in the intervention group received IV acetaminophen prior to IV opioids. Patients in the control group received IV opioids without IV acetaminophen. Main Outcomes and Measures Total duration of all IV opioids administered during a patient's hospitalization. Results Of 893 293 pediatric inpatients, a total of 104 579 were included in analysis (median [IQR] age, 1.3 [0-14.7] years; 59 806 [57.2%] female; 21 485 [21.5%] African American, 56 309 [53.8%] White), of whom 18 197 (2.0%) received IV acetaminophen, and 287 504 (34.0%) received IV opioids. After applying exclusion criteria, among patients who received IV acetaminophen, 1739 (10.8%) received IV acetaminophen prior to IV opioids within a median (IQR) treatment time of 1.5 (0.02-7.3) hours. After propensity score matching produced comparable groups in the control and intervention groups (with 839 patients in each group), the multivariable model estimated a 15.5% shorter duration of IV opioid use in the intervention group, with an absolute IV opioid reduction of 7.5 hours (95% CI, 0.7-15.8 hours). Conclusions and Relevance In this comparative effectiveness study, IV acetaminophen administered prior to IV opioids was associated with a reduction in IV opioid duration by 15.5%. Multimodal pain regimens that use IV acetaminophen prior to IV opioids could reduce IV opioid duration.
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Affiliation(s)
- Anita K. Patel
- Division of Critical Care Medicine, Department of Pediatrics, Children’s National Health System and George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Jiaxiang Gai
- Children’s National Health System and George Washington University School of Medicine and Health Sciences, Washington, DC
| | | | | | - Dongkyu Kim
- Department of Pediatrics, Children’s National Health System and George Washington University School of Medicine and Health Sciences, Washington, DC
| | - James E. Bost
- Children’s National Health System and George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Murray M. Pollack
- Division of Critical Care Medicine, Department of Pediatrics, Children’s National Health System and George Washington University School of Medicine and Health Sciences, Washington, DC
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Wang A, Tian X, Gu H, Zuo Y, Meng X, Chen P, Li H, Wang Y. Electrolytes and clinical outcomes in patients with acute ischemic stroke or transient ischemic attack. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1069. [PMID: 34422981 PMCID: PMC8339832 DOI: 10.21037/atm-21-741] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/02/2021] [Indexed: 11/06/2022]
Abstract
Background Abnormal electrolytes were closely related to the prognosis of various diseases, the prognostic role of electrolytes in stroke has not been investigated well. We aimed to investigate the association between electrolytes and clinical outcomes in patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA). Methods Data were recruited from the China National Stroke Registry III study. Patients were classified into three groups according to tertiles and the normal range of each electrolyte. Multivariable logistic and Cox proportional hazards regressions were adopted to explore the associations of electrolytes with poor functional outcomes [modified Rankin Scale (mRS) 3–6/2–6] and all-cause death at 3 months and 1 year. Results A total of 10,299 eligible patients were enrolled. After adjusted for confounding factors, the first tertile electrolytes were associated with increased risk of poor functional outcome (mRS score 3–6) at 1 year, the adjusted odds ratios (95% confidence intervals) were 1.33 (1.14–1.55) for potassium, 1.41 (1.20–1.60) for sodium, 1.27 (1.08–1.48) for chloride, compared with the second tertile. Similar results were found when poor functional outcome was defined as mRS score 2–6 and all-cause death. However, almost no significant association was present of calcium with these outcomes. All results were consistent when each electrolyte was classified into three groups according to the normal range and the outcomes timepoint was set at 3 months. Conclusions Lower levels of potassium, sodium, chloride but not calcium were associated with higher risk of poor functional outcomes and death in patients with AIS or TIA.
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Affiliation(s)
- Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xue Tian
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China.,Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing, China
| | - Hongqiu Gu
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yingting Zuo
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China.,Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing, China
| | - Xia Meng
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Pan Chen
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hao Li
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yongjun Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Mclean A, Nath M, Sawhney S. Population Epidemiology of Hyperkalemia: Cardiac and Kidney Long-term Health Outcomes. Am J Kidney Dis 2021; 79:527-538.e1. [PMID: 34419518 DOI: 10.1053/j.ajkd.2021.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 07/05/2021] [Indexed: 12/21/2022]
Abstract
RATIONALE & OBJECTIVE The population burden and long-term implications of hyperkalemia have not been comprehensively studied. We studied how often and where hyperkalemia occurs as well as its independent association with survival and long-term cardiac and kidney health. STUDY DESIGN Population-based cohort study of adult residents of Grampian, United Kingdom. SETTING & PARTICIPANTS Among the 468,594 adult residents (2012-2014), 302,630 people with at least 1 blood test were followed until 2019. EXPOSURE Hyperkalemia was defined as serum potassium ≥ 5.5 mmol/L. Adjustment for comorbidities, demographics, measures of acute and chronic kidney function, and medications prescribed before measurement of serum potassium. OUTCOME All-cause mortality, cardiac events, and kidney failure. ANALYTICAL APPROACH Description of the annual incidence of hyperkalemia and the characteristics associated with its occurrence, and adjusted Cox proportional hazards (PH) analysis to evaluate the independent long-term association of hyperkalemia with all-cause mortality among people who survived ≥90 days after blood testing. Cause-specific PH models were fit to evaluate the association of hyperkalemia with cardiac events/death, noncardiac death, and kidney failure. Effect modification by level of estimated glomerular filtration rate (eGFR) at the time of blood testing was explored. RESULTS The annual population incidence of hyperkalemia was 0.96 per 100 person-years. This represented 2.3%, 2.1%, and 1.9% of people with at least one blood test in 2012, 2013, and 2014, respectively. Two-thirds of episodes of hyperkalemia occurred in the community. The hyperkalemia rate was 2-fold higher for each 10-year greater age. Those with hyperkalemia were 20 times more likely to have concurrent acute kidney injury (AKI), and 17 times more likely to have an eGFR of <30 mL/min/1.73 m2. Throughout 5 years of follow-up evaluation (2,483,452 person-years), hyperkalemia was associated with poorer health outcomes. This association held across all levels of kidney function and was irrespective of concurrent AKI, but was stronger among those with a baseline eGFR of ≥60 mL/min/1.73 m2 (P for interaction < 0.001). The adjusted HRs (hyperkalemia vs no hyperkalemia) for people with eGFR ≥60 mL/min/1.73 m2 and eGFR <30 mL/min/1.73 m2 were 2.3 (95% CI, 2.2-2.5) and 1.5 (95% CI, 1.3-1.6) for mortality; 1.8 (95% CI, 1.6-1.9) and 1.4 (95% CI, 1.2-1.6) for cardiac events; and 17.0 (95% CI, 9.3-31.1) and 2.0 (95% CI, 1.5-2.8) for kidney failure, respectively. LIMITATIONS The observational nature of this study limits evaluation of causal relationships. CONCLUSIONS There is a substantial burden of hyperkalemia in the general population. Hyperkalemia is associated with poorer long-term health outcomes, especially kidney outcomes, that are independent of other established risk factors.
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Affiliation(s)
- Andrew Mclean
- Aberdeen Centre for Health Data Sciences, University of Aberdeen, Aberdeen, United Kingdom; National Health Service Grampian, Aberdeen, United Kingdom
| | - Mintu Nath
- Aberdeen Centre for Health Data Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Simon Sawhney
- Aberdeen Centre for Health Data Sciences, University of Aberdeen, Aberdeen, United Kingdom; National Health Service Grampian, Aberdeen, United Kingdom.
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Davis J, Israni R, Mu F, Cook EE, Szerlip H, Uwaifo G, Fonseca V, Betts KA. Inpatient management and post-discharge outcomes of hyperkalemia. Hosp Pract (1995) 2021; 49:273-279. [PMID: 34038312 PMCID: PMC9102837 DOI: 10.1080/21548331.2021.1925554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022]
Abstract
OBJECTIVES Patients with hyperkalemia are commonly treated in the inpatient setting; however, real-world evidence is limited. The purpose of this study was to describe the inpatient management and post-discharge outcomes among patients with hyperkalemia. METHODS Electronic medical record data (2012-2018) were used to analyze US adult patients with an inpatient stay with hyperkalemia (≥1 potassium value >5.0mEq/L). Patient characteristics, treatments, and monitoring six months prior to and during the inpatient stay, and hyperkalemia recurrence and inpatient readmissions post-discharge were summarized and compared among patients with mild (>5.0-5.5mEq/L), moderate (>5.5-6.0), and severe (>6.0) hyperkalemia. RESULTS Of the 21,793 patients, 69.2% had mild, 19.0% had moderate, and 11.8% had severe hyperkalemia during inpatient care. The most common inpatient treatments were temporizing agents (mild: 28.9%; moderate: 46.0%; severe: 73.0%), diuretics (32.7%; 37.1%; 34.6%), and sodium-polystyrene sulfonate (11.7%; 27.8%; 45.3%). Almost no patients (0.1%) received a potassium binder at discharge. Most patients (86.8%) had their potassium levels return to ≤5.0mEq/L during the inpatient stay. Death during the inpatient stay occurred in 12.3% of mild, 15.5% of moderate, and 19.5% of severe hyperkalemic patients. Within 30 days of discharge, hyperkalemia recurred in 13.3%, 15.4%, and 18.4% of patients with mild, moderate, and severe hyperkalemia, respectively. Additionally, 19.7%, 21.5%, and 19.6% of patients were readmitted to inpatient care within 30 days post-discharge. CONCLUSION Among patients with hyperkalemia in the inpatient setting, treatment and normalization of serum potassium levels were common. However, death, readmission, and hyperkalemia recurrence were also fairly common across all cohorts. Future studies examining measures to reduce inpatient death, readmission, and hyperkalemia recurrence among patients with hyperkalemia in inpatient care are warranted.
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Affiliation(s)
| | | | - Fan Mu
- Analysis Group, Inc, Boston, Massachusetts, USA
| | - Erin E Cook
- Analysis Group, Inc, Boston, Massachusetts, USA
| | | | | | - Vivian Fonseca
- Tulane University Medical Center, Tulane University School of Medicine, New Orleans, Louisiana, USA
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Tamargo J, Caballero R, Delpón E. The pharmacotherapeutic management of hyperkalemia in patients with cardiovascular disease. Expert Opin Pharmacother 2021; 22:1319-1341. [PMID: 33620275 DOI: 10.1080/14656566.2021.1891223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Patients with cardiovascular diseases (CVD) are at increased risk of hyperkalemia, particularly when treated with renin-angiotensin-aldosterone inhibitors (RAASIs). Because the occurrence or fear of hyperkalemia, RAASIs are frequently down-titrated or discontinued in patients with CVD, with consequent worse outcomes than patients who remain on maximum doses.Areas covered: This article reviews potassium homeostasis, epidemiology, risk factors, and outcomes of hyperkalemia, and efficacy and safety of the drugs used for acute and chronic treatment of hyperkalemia. A literature search was carried out using the PubMed and guidelines for the management of hyperkalemia.Expert opinion: The emergency treatment of hyperkalemia is not supported by high-quality evidence and clinical trials did not report drug effects on clinical outcomes. Two potassium binders, patiromer and sodium zirconium cyclosilicate, represent a new approach in the treatment of chronic hyperkalemia as they may allow the titration and maintenance of guidelines-recommended doses of RAASIs in patients with CVD who otherwise would not tolerate them due to the risk of hyperkalemia.Further studies are needed to evaluate the safety and efficacy of drug therapy and support the development of guidelines for acute and chronic hyperkalemia.
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Affiliation(s)
- Juan Tamargo
- Department of Pharmacology, School of Medicine, Universidad Complutense, Instituto De Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Ricardo Caballero
- Department of Pharmacology, School of Medicine, Universidad Complutense, Instituto De Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Eva Delpón
- Department of Pharmacology, School of Medicine, Universidad Complutense, Instituto De Investigación Sanitaria Gregorio Marañón, Madrid, Spain
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Palmer BF, Carrero JJ, Clegg DJ, Colbert GB, Emmett M, Fishbane S, Hain DJ, Lerma E, Onuigbo M, Rastogi A, Roger SD, Spinowitz BS, Weir MR. Clinical Management of Hyperkalemia. Mayo Clin Proc 2021; 96:744-762. [PMID: 33160639 DOI: 10.1016/j.mayocp.2020.06.014] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/18/2020] [Accepted: 06/10/2020] [Indexed: 12/26/2022]
Abstract
Hyperkalemia is an electrolyte abnormality with potentially life-threatening consequences. Despite various guidelines, no universally accepted consensus exists on best practices for hyperkalemia monitoring, with variations in precise potassium (K+) concentration thresholds or for the management of acute or chronic hyperkalemia. Based on the available evidence, this review identifies several critical issues and unmet needs with regard to the management of hyperkalemia. Real-world studies are needed for a better understanding of the prevalence of hyperkalemia outside the clinical trial setting. There is a need to improve effective management of hyperkalemia, including classification and K+ monitoring, when to reinitiate previously discontinued renin-angiotensin-aldosterone system inhibitor (RAASi) therapy, and when to use oral K+-binding agents. Monitoring serum K+ should be individualized; however, increased frequency of monitoring should be considered for patients with chronic kidney disease, diabetes, heart failure, or a history of hyperkalemia and for those receiving RAASi therapy. Recent clinical studies suggest that the newer K+ binders (patiromer sorbitex calcium and sodium zirconium cyclosilicate) may facilitate optimization of RAASi therapy. Enhancing the knowledge of primary care physicians and internists with respect to the safety profiles of these newer K+ binders may increase confidence in managing patients with hyperkalemia. Lastly, the availability of newer K+-binding agents requires further study to establish whether stringent dietary K+ restrictions are needed in patients receiving K+-binder therapy. Individualized monitoring of serum K+ among patients with an increased risk of hyperkalemia and the use of newer K+-binding agents may allow for optimization of RAASi therapy and more effective management of hyperkalemia.
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Affiliation(s)
- Biff F Palmer
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas.
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Deborah J Clegg
- Drexel University College of Nursing and Health Professions, Philadelphia, PA
| | | | | | - Steven Fishbane
- Department of Medicine, Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY
| | - Debra J Hain
- Christine E. Lynn College of Nursing, Florida Atlantic University, and Cleveland Clinic Florida, Weston, FL
| | - Edgar Lerma
- Department of Medicine, University of Illinois at Chicago/Advocate Christ Medical Center, Oak Lawn
| | - Macaulay Onuigbo
- Robert Larner College of Medicine, University of Vermont Medical Center, Burlington
| | - Anjay Rastogi
- David Geffen School of Medicine, University of California, Los Angeles
| | - Simon D Roger
- Renal Research, Gosford Hospital, Gosford, Australia
| | | | - Matthew R Weir
- Department of Medicine, University of Maryland School of Medicine, Baltimore
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10
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Mizuguchi Y, Konishi T, Nagai T, Sato T, Takenaka S, Tada A, Kobayashi Y, Komoriyama H, Kato Y, Omote K, Sato T, Kamiya K, Tsujinaga S, Iwano H, Kikuchi K, Tanaka S, Anzai T. Prognostic value of admission serum magnesium in acute myocardial infarction complicated by malignant ventricular arrhythmias. Am J Emerg Med 2021; 44:100-105. [PMID: 33582610 DOI: 10.1016/j.ajem.2021.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 01/06/2021] [Accepted: 02/01/2021] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES Although electrolyte abnormalities are related to worse clinical outcomes in patients with acute myocardial infarction (AMI), little is known about the association between admission serum magnesium level and adverse events in AMI patients complicated by out-of-hospital cardiac arrest presenting with malignant ventricular arrhythmias (OHCA-MVA). We investigated the prognostic value of serum magnesium level on admission in these patients. METHODS We retrospectively analyzed the data of 165 consecutive reperfused AMI patients complicated with OHCA-MVA between April 2007 and February 2020 in our university hospital. Serum magnesium concentration was measured on admission. The primary outcome was in-hospital death. RESULTS Fifty-four patients (33%) died during hospitalization. Higher serum magnesium level was significantly related to in-hospital death (Fine & Gray's test; p < 0.001). In multivariable logistic regression analyses, serum magnesium level on admission was independently associated with in-hospital death (hazard ratio 2.68, 95% confidence interval 1.24-5.80) even after adjustment for covariates. Furthermore, the incidences of cardiogenic shock necessitating an intra-aortic balloon pump (p = 0.005) or extracorporeal membrane oxygenation (p < 0.001), tracheal intubation (p < 0.001) and persistent vegetative state (p = 0.002) were significantly higher in patients with higher serum magnesium level than in those with lower serum magnesium level. CONCLUSIONS In reperfused AMI patients complicated by OHCA-MVA, admission serum magnesium level might be a potential surrogate marker for predicting in-hospital death.
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Affiliation(s)
- Yoshifumi Mizuguchi
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Takao Konishi
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan.
| | - Tomoya Sato
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Sakae Takenaka
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Atsushi Tada
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yuta Kobayashi
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hirokazu Komoriyama
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yoshiya Kato
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kazunori Omote
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Takuma Sato
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kiwamu Kamiya
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Shingo Tsujinaga
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroyuki Iwano
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kenjiro Kikuchi
- Department of Cardiology, Minami-ichijo Hospital, Sapporo, Japan
| | - Shinya Tanaka
- Department of Cancer Pathology, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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11
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Potassium variability during hospitalization and outcomes after discharge in patients with acute myocardial infarction. J Geriatr Cardiol 2021; 18:10-19. [PMID: 33613655 PMCID: PMC7868917 DOI: 10.11909/j.issn.1671-5411.2021.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The variability of metabolic biomarkers has been determined to provide incremental prognosis information, but the implications of electrolyte variability remained unclear. METHODS We investigate the relationships between electrolyte fluctuation and outcomes in survivors of acute myocardial infarction (n = 4386). Ion variability was calculated as the coefficient of variation, standard deviation, variability independent of the mean (VIM) and range. Hazard ratios (HR) were estimated using the multivariable-adjusted Cox proportional regression method. RESULTS During a median follow-up of 12 months, 161 (3.7%) patients died, and heart failure occurred in 550 (12.5%) participants after discharge, respectively. Compared with the bottom quartile, the highest quartile potassium VIM was associated with increased risks of all-cause mortality (HR = 2.35, 95% CI: 1.36-4.06) and heart failure (HR = 1.32, 95% CI: 1.01-1.72) independent of cardiac troponin I (cTnI), N terminal pro B type natriuretic peptide (NT-proBNP), infarction site, mean potassium and other traditional factors, while those associations across sodium VIM quartiles were insignificant. Similar trend remains across the strata of variability by other three indices. These associations were consistent after excluding patients with any extreme electrolyte value and diuretic use. CONCLUSIONS Higher potassium variability but not sodium variability was associated with adverse outcomes post-infarction. Our findings highlight that potassium variability remains a robust risk factor for mortality regardless of clinical dysnatraemia and dyskalaemia.
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12
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Khan AH, Gai J, Faruque F, Bost JE, Patel AK, Pollack MM. Pediatric Mortality and Acute Kidney Injury Are Associated with Chloride Abnormalities in Intensive Care Units in the United States: A Multicenter Observational Study. J Pediatr Intensive Care 2020; 11:91-99. [DOI: 10.1055/s-0040-1719172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 09/28/2020] [Indexed: 01/19/2023] Open
Abstract
AbstractOur objective was to determine in children in the intensive care unit (ICU) the incidence of hyperchloremia (>110 mmol/L) and hypochloremia (<98 mmol/L), the association of diagnoses with chloride abnormalities, and the associations of mortality and acute kidney injury (AKI) with chloride abnormalities. We analyzed the initial, maximum, and minimum chloride measurements of 14,684 children in the ICU with ≥1 chloride measurement in the Health Facts database between 2009 and 2016. For hyperchloremia and hypochloremia compared with normochloremia, mortality rates increased three to fivefold and AKI rates increased 1.5 to threefold. The highest mortality rate (7.7%; n = 95/1,234) occurred with hyperchloremia in the minimum chloride measurement group and the highest AKI rate (7.7%; n = 72/930) occurred with hypochloremia in the initial chloride measurement group. The most common diagnostic categories associated with chloride abnormalities were injury and poisoning; respiratory; central nervous system; infectious and parasitic diseases; and endocrine, nutritional, metabolic, and immunity disorders. Controlled for race, gender, age, and diagnostic categories, mortality odds ratios, and AKI odds ratios were significantly higher for hyperchloremia and hypochloremia compared with normochloremia. In conclusion, hyperchloremia and hypochloremia are independently associated with mortality and AKI in children in the ICU.
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Affiliation(s)
- Aamer H. Khan
- Division of Critical Care Medicine, Children's National Hospital, Washington, District of Columbia, United States
| | - Jiaxing Gai
- Division of Critical Care Medicine, Children's National Hospital, Washington, District of Columbia, United States
| | - Farhana Faruque
- Division of Critical Care Medicine, Children's National Hospital, Washington, District of Columbia, United States
| | - James E. Bost
- Division of Biostatistics and Study Methodology, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, United States
| | - Anita K. Patel
- Division of Critical Care Medicine, Children's National Hospital, Washington, District of Columbia, United States
- Division of Biostatistics and Study Methodology, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, United States
| | - Murray M. Pollack
- Division of Critical Care Medicine, Children's National Hospital, Washington, District of Columbia, United States
- Division of Biostatistics and Study Methodology, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, United States
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13
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Alrashidi TN, Alregaibah RA, Alshamrani KA, Alhammad AA, Alyami RHA, Almadhi MA, Ahmed ME, Almodaimegh H. Hyperkalemia Among Hospitalized Patients and Association Between Duration of Hyperkalemia and Outcomes. Cureus 2020; 12:e10401. [PMID: 33062520 PMCID: PMC7550028 DOI: 10.7759/cureus.10401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Hyperkalemia is a serious life-threatening condition that leads to significant morbidity and mortality. Objectives The aim of this study is to investigate the association between the duration and outcomes in patients hospitalized with hyperkalemia, as well as associated risk factors and drug-induced hyperkalemia. Methods A three-year retrospective chart review study was conducted at a tertiary hospital at King Abdulaziz Medical City, Riyadh, Saudi Arabia, between January 2016 and April 2019. We included all hospitalized adults and patients with hyperkalemia. Pediatric patients and dialysis patients with end-stage renal failure were excluded. Results Out of a total of 300 hospitalized patients who were screened for hyperkalemia, only 142 patients were included. The majority of cases were males (56.3%), whereas 43.7% were females. Most patients were above 55 years old. Regarding comorbidities in patients with hyperkalemia, most of them suffered from high blood pressure or diabetes. The mean serum potassium value was 5.7 ± 0.51 mEq. The most frequent medications used in the study population were azole antifungal medication followed by nonsteroidal anti-inflammatory drugs, beta-blockers, and angiotensin-converting enzyme inhibitors. Around 54 patients were not treated with medication and were monitored for spontaneous correction of hyperkalemia. Insulin was the most used medication for the treatment of hyperkalemia. The mean duration for the resolution of hyperkalemia was 12 ±9.4 hours. Out of 142 patients, only 10 (7%) patients died with hyperkalemia. Conclusions Hospitalized patients are at risk of hyperkalemia. In our study, we found that patients who had hyperkalemia were significantly likely to have acute kidney injury or cardiovascular diseases, and azole antifungals and beta-blockers were the most commonly used medications.
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Affiliation(s)
| | | | | | - Ahmed A Alhammad
- Emergency Medicine, College of Medicine, King Abdulaziz University, Jeddah, SAU
| | | | - Mawadda Abdullah Almadhi
- Emergency Medicine, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Mohamed E Ahmed
- Biostatistics, King Abdullah International Medical Research Center, Jeddah, SAU
| | - Hind Almodaimegh
- Pharmacology and Therapeutics, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, SAU
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14
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Takkar C, Nassar T, Qunibi W. An evaluation of sodium zirconium cyclosilicate as a treatment option for hyperkalemia. Expert Opin Pharmacother 2020; 22:19-28. [PMID: 32892634 DOI: 10.1080/14656566.2020.1810234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Hyperkalemia, defined as serum potassium level > 5.0 mEq/l, is associated with serious cardiac dysrhythmias, sudden death and increased mortality risk. It is common in patients with chronic kidney disease (CKD), diabetes (DM) and heart failure (HF), particularly in those treated with the renin-angiotensin-aldosterone system (RAAS) inhibitors or potassium-sparing diuretics. Although these drugs have documented renal and cardiac protective benefits, frequent hyperkalemia associated with their use often dictates administration of suboptimal doses or their discontinuation altogether. Treatment for chronic hyperkalemia in these settings has been challenging; however, the recent introduction of two new potassium-binding resins has revolutionized our approach to treating hyperkalemia. AREAS COVERED We review key clinical data relating to the pharmacokinetics, efficacy and safety of sodium zirconium cyclosilicate (SZC) as a treatment option for hyperkalemia. EXPERT OPINION SZC and Patiromer are promising new agents for lowering serum potassium in hyperkalemic patients, including those with CKD, with and without DM or HF, facilitating the use of the RAAS inhibitors for renal and cardiac protection. Recent randomized clinical trials have shown that SZC effectively lowers serum potassium and maintains normokalemia in most hyperkalemic patients. Clinical trials showed that SZC lowers serum potassium within 1 h, although it is not approved for treating acute hyperkalemia. SZC was well tolerated and associated with minimal adverse effects.
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Affiliation(s)
- Chandan Takkar
- Internal Medicine, Division of Nephrology, University of Texas Health Science Center at San Antonio , San Antonio, USA
| | - Tareq Nassar
- Division of Nephrology, University of Texas Health Science Center at San Antonio, Internal Medicine , San Antonio, USA
| | - Wajeh Qunibi
- Internal Medicine, Division of Nephrology, University of Texas Health Science Centre and Texas Diabetes Institute , San Antonio, USA
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15
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Sedation, Analgesia, and Neuromuscular Blockade: An Assessment of Practices From 2009 to 2016 in a National Sample of 66,443 Pediatric Patients Cared for in the ICU. Pediatr Crit Care Med 2020; 21:e599-e609. [PMID: 32195896 PMCID: PMC7483172 DOI: 10.1097/pcc.0000000000002351] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To describe the pharmaceutical management of sedation, analgesia, and neuromuscular blockade medications administered to children in ICUs. DESIGN A retrospective analysis using data extracted from the national database Health Facts. SETTING One hundred sixty-one ICUs in the United States with pediatric admissions. PATIENTS Children in ICUs receiving medications from 2009 to 2016. EXPOSURE/INTERVENTION Frequency and duration of administration of sedation, analgesia, and neuromuscular blockade medications. MEASUREMENTS AND MAIN RESULTS Of 66,443 patients with a median age of 1.3 years (interquartile range, 0-14.5), 63.3% (n = 42,070) received nonopioid analgesic, opioid analgesic, sedative, and/or neuromuscular blockade medications consisting of 83 different agents. Opioid and nonopioid analgesics were dispensed to 58.4% (n = 38,776), of which nonopioid analgesics were prescribed to 67.4% (n = 26,149). Median duration of opioid analgesic administration was 32 hours (interquartile range, 7-92). Sedatives were dispensed to 39.8% (n = 26,441) for a median duration of 23 hours (interquartile range, 3-84), of which benzodiazepines were most common (73.4%; n = 19,426). Neuromuscular-blocking agents were dispensed to 17.3% (n = 11,517) for a median duration of 2 hours (interquartile range, 1-15). Younger age was associated with longer durations in all medication classes. A greater proportion of operative patients received these medication classes for a longer duration than nonoperative patients. A greater proportion of patients with musculoskeletal and hematologic/oncologic diseases received these medication classes. CONCLUSIONS Analgesic, sedative, and neuromuscular-blocking medications were prescribed to 63.3% of children in ICUs. The durations of opioid analgesic and sedative medication administration found in this study can be associated with known complications, including tolerance and withdrawal. Several medications dispensed to pediatric patients in this analysis are in conflict with Food and Drug Administration warnings, suggesting that there is potential risk in current sedation and analgesia practice that could be reduced with practice changes to improve efficacy and minimize risks.
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16
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Abstract
OBJECTIVE To examine medication administration records through electronic health record data to provide a broad description of the pharmaceutical exposure of critically ill children. DESIGN Retrospective cohort study using the Cerner Health Facts database. SETTING United States. PATIENTS A total of 43,374 children 7 days old to less than 22 years old receiving intensive care with available pharmacy data. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 907,440 courses of 1,080 unique medications were prescribed with a median of nine medications (range, 1-99; 25-75th percentile, 5-16) per patient. The most common medications were acetaminophen, ondansetron, and morphine. Only 45 medications (4.2%) were prescribed to more than 5% of patients, and these accounted for 442,067 (48.7%) of the total courses of medications. Each additional medication was associated with increased univariate risk of mortality (odds ratio, 1.05; 95% CI, 1.05-1.06; p < 0.001). CONCLUSIONS Children receiving intensive care receive a median of nine medications per patient and one quarter are prescribed at least than 16 medications. Only 45 medications were prescribed to more than 5% of patients, but these accounted for almost half of all medication courses.
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17
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Xi H, Yu RH, Wang N, Chen XZ, Zhang WC, Hong T. Serum potassium levels and mortality of patients with acute myocardial infarction: A systematic review and meta-analysis of cohort studies. Eur J Prev Cardiol 2020; 26:145-156. [PMID: 31060369 DOI: 10.1177/2047487318780466] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The evidence of current epidemiological studies investigating the association between serum potassium levels and mortality of acute myocardial infarction (AMI) patients is controversial and inadequate. DESIGN Systematic review and meta-analysis. METHODS Two researchers independently searched the PubMed, EMBASE and Web of Science databases to identify observational studies published prior to 31 October 2017. Similarly, two researchers separately extracted data and any differences were resolved by discussion. Pooled relative risks and 95% confidence intervals (CIs) were computed with an inverse variance-weighted random-effects model. Heterogeneity among studies was assessed with the I2 statistic. RESULTS Seven cohort studies were included for analysis. Compared with the reference group (3.5 to <4.0 mEq/L), the pooled relative risks of mortality were 1.15 (95% CI = 1.00-1.32), 1.09 (95% CI = 0.97-1.24), 1.42 (95% CI = 1.19-1.70) and 1.85 (95% CI = 1.39-2.47) for AMI patients with a potassium level of<3.5, 4.0 to <4.5, 4.5 to <5.0, and ≥5.0 mEq/L, respectively. For admission and post-admission potassium, although J-shaped associations were also indicated, non-significant results were observed for AMI patients with potassium levels of <3.5 mEq/L when compared with the reference group. Notably, in subgroup analyses of study characteristics, stratified by study quality, geographic location, type of outcome, number of cases, type of AMI, and adjustment for potential confounders, the findings were broadly consistent across strata. CONCLUSIONS These findings indicate that both lower (<3.5 mEq/L) and higher (≥4.5 mEq/L) serum potassium levels are associated with an increased risk of mortality of patients with AMI.
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Affiliation(s)
- Hui Xi
- 1 Department of Cardiology, Peking University International Hospital, Beijing, China
| | - Rong-Hui Yu
- 2 Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ning Wang
- 1 Department of Cardiology, Peking University International Hospital, Beijing, China
| | - Xue-Zhi Chen
- 1 Department of Cardiology, Peking University International Hospital, Beijing, China
| | - Wen-Chao Zhang
- 1 Department of Cardiology, Peking University International Hospital, Beijing, China
| | - Tao Hong
- 3 Department of Cardiology, Peking University First Hospital, Beijing, China
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18
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Plakht Y, Gad Saad SN, Gilutz H, Shiyovich A. Potassium levels as a marker of imminent acute kidney injury among patients admitted with acute myocardial infarction. Soroka Acute Myocardial Infarction II (SAMI-II) Project. Int J Cardiol 2020; 322:214-219. [PMID: 32800913 DOI: 10.1016/j.ijcard.2020.08.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 06/16/2020] [Accepted: 08/07/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common complication following acute myocardial infarction (AMI) and associated with worse outcomes. Serum Potassium levels (K, mEq/L), which are regulated by the kidneys, are related with poor prognosis in patients with AMI. OBJECTIV To evaluate whether K levels predict imminent AKI in patients with AMI. METHODS This retrospective nested case-control study was based on medical records of hospitalized AMI patients, 2002-2012. The cases (AKI group) were defined as an increase of ≥1.5-fold in serum creatinine level or a decrease of ≥25% in the estimated glomerular filtration rate (eGFR) during the hospitalization. The control group comprised of matched randomly selected patients that did not develop AKI. For both groups, all creatinine and K levels were obtained for up-to 72 h prior to the AKI diagnosis (index time). RESULTS A total of 12,498/17,678 admissions met the inclusion criteria. The AKI and the control groups consisted of 430 and 1345 matched admission respectively. K levels, prior AKI diagnosis seemed to be higher in the AKI group. Multivariate analysis showed that K ≥ 4.5 within 36-56 h prior to the index time was an independent predictor of the subsequent AKI, OR = 2.3, p < .001. The c-statistic of the model was 0.859, p < .001. Predictivity of K for AKI was stronger among ST-elevation (STEMI) vs. Non-ST-elevation AMI (NSTEMI) patients (OR = 4, p < .001 vs. 1.7, p = .025 respectively; p-for-interaction = 0.038). CONCLUSIONS K ≥ 4.5 is an independent and incremental marker of imminent AKI in patients with AMI, predictivity is stronger in patients with STEMI than NSTEMI.
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Affiliation(s)
- Ygal Plakht
- Department of Nursing, Faculty of Health Sciences, Ben-Gurion University of the Negev, Soroka University Medical Center, Beer-Sheva, Israel.
| | - Shiran Nili Gad Saad
- Department of Nursing, Faculty of Health Sciences, Ben-Gurion University of the Negev, Soroka University Medical Center, Beer-Sheva, Israel
| | - Harel Gilutz
- Goldman Medical School, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Arthur Shiyovich
- Department of Cardiology, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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19
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Brueske B, Sidhu MS, Schulman-Marcus J, Kashani KB, Barsness GW, Jentzer JC. Hyperkalemia Is Associated With Increased Mortality Among Unselected Cardiac Intensive Care Unit Patients. J Am Heart Assoc 2020; 8:e011814. [PMID: 30922150 PMCID: PMC6509722 DOI: 10.1161/jaha.118.011814] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background Hyperkalemia has been associated with increased mortality in patients with myocardial infarction, but few data exist regarding hyperkalemia in cardiac intensive care unit (CICU) patients. We hypothesize that hyperkalemia is associated with increased mortality in unselected CICU patients. Methods and Results We retrospectively reviewed a historical cohort of 9681 CICU patients admitted from January 2007 to December 2015. Hyperkalemia was defined as admission potassium ≥5.0 mEq/L and hypokalemia as admission potassium <3.5 mEq/L. Multivariate logistic regression was used to determine predictors of in‐hospital mortality. Postdischarge survival was assessed using Kaplan–Meier analysis and Cox proportional hazards models. The mean age of included patients was 67±15 years, with 36% females, and in‐hospital mortality was 9%. Hyperkalemia occurred in 1187 (12.3%) and hypokalemia occurred in 719 (7.4%) patients. Both patients with hyperkalemia (unadjusted odds ratio, 2.85; 95% CI, 2.40–3.39; P<0.001) and patients with hypokalemia (unadjusted odds ratio, 2.31; 95% CI, 1.85–2.88; P<0.001) were at increased risk of unadjusted in‐hospital mortality. After adjustment for illness severity and renal function, only patients with hyperkalemia demonstrated increased risk of in‐hospital death (adjusted odds ratio, 1.44; 95% CI, 1.11–1.87; P=0.006). Among hospital survivors, only patients with hyperkalemia had lower postdischarge survival by Kaplan–Meier analysis (P<0.001). After adjustment for illness severity and renal function, hospital survivors with admission hyperkalemia remained at increased risk for postdischarge mortality (adjusted hazard ratio, 1.20; 95% CI, 1.08–1.34; P<0.001). Conclusions Hyperkalemia on CICU admission is associated with higher in‐hospital and postdischarge mortality, independent of renal function and illness severity. These findings emphasize the importance of potassium abnormalities as a risk predictor in patients admitted to the CICU.
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Affiliation(s)
- Benjamin Brueske
- 1 Division of Cardiology Department of Medicine Albany Medical Center Albany NY
| | - Mandeep S Sidhu
- 1 Division of Cardiology Department of Medicine Albany Medical Center Albany NY
| | | | - Kianoush B Kashani
- 2 Division of Nephrology & Hypertension Department of Internal Medicine Mayo Clinic Rochester MN.,3 Division of Pulmonary and Critical Care Medicine Department of Internal Medicine Mayo Clinic Rochester MN
| | | | - Jacob C Jentzer
- 3 Division of Pulmonary and Critical Care Medicine Department of Internal Medicine Mayo Clinic Rochester MN.,4 Department of Cardiovascular Medicine Mayo Clinic Rochester MN
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20
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Gasparini A, Evans M, Barany P, Xu H, Jernberg T, Ärnlöv J, Lund LH, Carrero JJ. Plasma potassium ranges associated with mortality across stages of chronic kidney disease: the Stockholm CREAtinine Measurements (SCREAM) project. Nephrol Dial Transplant 2020; 34:1534-1541. [PMID: 30085251 PMCID: PMC6735645 DOI: 10.1093/ndt/gfy249] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Indexed: 12/16/2022] Open
Abstract
Background Small-scale studies suggest that hyperkalaemia is a less threatening condition in chronic kidney disease (CKD), arguing adaptation/tolerance to potassium (K+) retention. This study formally evaluates this hypothesis by estimating the distribution of plasma K+ and its association with mortality across CKD stages. Methods This observational study included all patients undergoing plasma K+ testing in Stockholm during 2006–11. We randomly selected one K+ measurement per patient and constructed a cross-sectional cohort with mortality follow-up. Covariates included demographics, comorbidities, medications and estimated glomerular filtration rate (eGFR). We estimated K+ distribution and defined K+ ranges associated with 90-, 180- and 365-day mortality. Results Included were 831 760 participants, of which 70 403 (8.5%) had CKD G3 (eGFR <60–30 mL/min) and 8594 (1.1%) had CKD G4–G5 (eGFR <30 mL/min). About 66 317 deaths occurred within a year. Adjusted plasma K+ increased across worse CKD stages: from median 3.98 (95% confidence interval 3.49–4.59) for eGFR >90 to 4.43 (3.22–5.65) mmol/L for eGFR ≤15 mL/min/1.73 m2. The association between K+ and mortality was U-shaped, but it flattened at lower eGFR strata and shifted upwards. For instance, the range where the 90-day mortality risk increased by no more than 100% was 3.45–4.94 mmol/L in eGFR >60 mL/min, but was 3.36–5.18 in G3 and 3.26–5.53 mmol/L in G4–G5. In conclusion, CKD stage modifies K+ distribution and the ranges that predict mortality in the community. Conclusion Although this study supports the view that hyperkalaemia is better tolerated with worse CKD, it challenges the current use of a single optimal K+ range for all patients.
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Affiliation(s)
| | - Marie Evans
- Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Peter Barany
- Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | | | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Johan Ärnlöv
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - Lars H Lund
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Juan-Jesús Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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21
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Rhee C, Zhang Z, Kadri SS, Murphy DJ, Martin GS, Overton E, Seymour CW, Angus DC, Dantes R, Epstein L, Fram D, Schaaf R, Wang R, Klompas M. Sepsis Surveillance Using Adult Sepsis Events Simplified eSOFA Criteria Versus Sepsis-3 Sequential Organ Failure Assessment Criteria. Crit Care Med 2019; 47:307-314. [PMID: 30768498 PMCID: PMC6383796 DOI: 10.1097/ccm.0000000000003521] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Sepsis-3 defines organ dysfunction as an increase in the Sequential Organ Failure Assessment score by greater than or equal to 2 points. However, some Sequential Organ Failure Assessment score components are not routinely recorded in all hospitals' electronic health record systems, limiting its utility for wide-scale sepsis surveillance. The Centers for Disease Control and Prevention recently released the Adult Sepsis Event surveillance definition that includes simplified organ dysfunction criteria optimized for electronic health records (eSOFA). We compared eSOFA versus Sequential Organ Failure Assessment with regard to sepsis prevalence, overlap, and outcomes. DESIGN Retrospective cohort study. SETTING One hundred eleven U.S. hospitals in the Cerner HealthFacts dataset. PATIENTS Adults hospitalized in 2013-2015. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We identified clinical indicators of presumed infection (blood cultures and antibiotics) concurrent with either: 1) an increase in Sequential Organ Failure Assessment score by 2 or more points (Sepsis-3) or 2) 1 or more eSOFA criteria: vasopressor initiation, mechanical ventilation initiation, lactate greater than or equal to 2.0 mmol/L, doubling in creatinine, doubling in bilirubin to greater than or equal to 2.0 mg/dL, or greater than or equal to 50% decrease in platelet count to less than 100 cells/μL (Centers for Disease Control and Prevention Adult Sepsis Event). We compared area under the receiver operating characteristic curves for discriminating in-hospital mortality, adjusting for baseline characteristics. Of 942,360 patients in the cohort, 57,242 (6.1%) had sepsis by Sequential Organ Failure Assessment versus 41,618 (4.4%) by eSOFA. Agreement between sepsis by Sequential Organ Failure Assessment and eSOFA was good (Cronbach's alpha 0.81). Baseline characteristics and infectious diagnoses were similar, but mortality was higher with eSOFA (17.1%) versus Sequential Organ Failure Assessment (14.4%; p < 0.001) as was discrimination for mortality (area under the receiver operating characteristic curve, 0.774 vs 0.759; p < 0.001). Comparisons were consistent across subgroups of age, infectious diagnoses, and comorbidities. CONCLUSIONS The Adult Sepsis Event's eSOFA organ dysfunction criteria identify a smaller, more severely ill sepsis cohort compared with the Sequential Organ Failure Assessment score, but with good overlap and similar clinical characteristics. Adult Sepsis Events may facilitate wide-scale automated sepsis surveillance that tracks closely with the more complex Sepsis-3 criteria.
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Affiliation(s)
- Chanu Rhee
- Department of Population Medicine, Harvard Medical School / Harvard Pilgrim Health Care Institute, Boston MA
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Zilu Zhang
- Department of Population Medicine, Harvard Medical School / Harvard Pilgrim Health Care Institute, Boston MA
| | - Sameer S. Kadri
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD
| | - David J. Murphy
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, and Emory Critical Care Center, Atlanta, GA
| | - Greg S. Martin
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, and Emory Critical Care Center, Atlanta, GA
| | - Elizabeth Overton
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, and Emory Critical Care Center, Atlanta, GA
| | - Christopher W. Seymour
- The Clinical Research, Investigation and Systems Modeling of Acute illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Derek C. Angus
- The Clinical Research, Investigation and Systems Modeling of Acute illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Raymund Dantes
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
- Division of Hospital Medicine, Emory University School of Medicine, Atlanta, GA
| | - Lauren Epstein
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | | | | | - Rui Wang
- Department of Population Medicine, Harvard Medical School / Harvard Pilgrim Health Care Institute, Boston MA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School / Harvard Pilgrim Health Care Institute, Boston MA
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA
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Peacock WF, Rafique Z, Clark CL, Singer AJ, Turner S, Miller J, Char D, Lagina A, Smith LM, Blomkalns AL, Caterino JM, Kosiborod M. Real World Evidence for Treatment of Hyperkalemia in the Emergency Department (REVEAL–ED): A Multicenter, Prospective, Observational Study. J Emerg Med 2018; 55:741-750. [DOI: 10.1016/j.jemermed.2018.09.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 08/21/2018] [Accepted: 09/01/2018] [Indexed: 11/16/2022]
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Imoto K, Hirakawa M, Okada M, Yamawaki H. Canstatin modulates L-type calcium channel activity in rat ventricular cardiomyocytes. Biochem Biophys Res Commun 2018; 499:954-959. [PMID: 29626474 DOI: 10.1016/j.bbrc.2018.04.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 04/03/2018] [Indexed: 12/24/2022]
Abstract
Excessive increase of cytosolic Ca2+ through the activation of L-type Ca2+ channels (LTCCs) via β adrenergic receptor induces apoptosis of cardiomyocytes. Canstatin, a cleaved fragment of collagen type IV α2 chain, is abundantly expressed in normal heart tissue. We previously reported that canstatin inhibits β adrenergic receptor-stimulated apoptosis in cardiomyoblasts. Here, we tested the hypothesis that canstatin regulates LTCCs activity in ventricular cardiomyocytes. Collagen type IV α2 chain (COL4A2) small interfering (si) RNA (for canstatin suppression) or control siRNA was injected via jugular vein in Wistar rats. Two days after the injection, electrocardiogram (ECG) was recorded and the left ventricular tissue was isolated using Langendorff apparatus. Immunofluorescence staining was performed to clarify the distribution of canstatin in cardiomyocytes. The knockdown efficiency was confirmed by Western blotting. The L-type Ca2+ channel current (ICaL) of ventricular cardiomyocyte was measured by a whole-cell patch clamp technique. In immunofluorescence staining, colocalization of canstatin and αv integrin was observed in the isolated ventricular cardiomyocytes. The ICaL of ventricular cardiomyocyte isolated from COL4A2 siRNA-injected rats was significantly enhanced compared with control siRNA-injected rats. Recombinant canstatin (250 ng/ml) significantly reversed it. ECG analysis showed that QT interval tended to be shortened and amplitude of T wave was significantly increased in the COL4A2 siRNA-injected rats. In summary, we for the first time clarified that suppressing canstatin expression increases the basal ICaL in ventricular cardiomyocytes. It is proposed that canstatin might play a role in the stabilization of cardiac function through the modulation of LTCC activity in cardiomyocytes.
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Affiliation(s)
- Keisuke Imoto
- Laboratory of Veterinary Pharmacology, School of Veterinary Medicine, Kitasato University, Japan
| | - Masaki Hirakawa
- Laboratory of Veterinary Pharmacology, School of Veterinary Medicine, Kitasato University, Japan
| | - Muneyoshi Okada
- Laboratory of Veterinary Pharmacology, School of Veterinary Medicine, Kitasato University, Japan.
| | - Hideyuki Yamawaki
- Laboratory of Veterinary Pharmacology, School of Veterinary Medicine, Kitasato University, Japan
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24
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Colombo MG, Kirchberger I, Amann U, Dinser L, Meisinger C. Association of serum potassium concentration with mortality and ventricular arrhythmias in patients with acute myocardial infarction: A systematic review and meta-analysis. Eur J Prev Cardiol 2018; 25:576-595. [DOI: 10.1177/2047487318759694] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Challenging clinical practice guidelines that recommend serum potassium concentration between 4.0–5.0 mEq/L or ≥4.5 mEq/L in patients with acute myocardial infarction, recent studies found increased mortality risks in patients with a serum potassium concentration of ≥4.5 mEq/L. Studies investigating consequences of hypokalemia after acute myocardial infarction revealed conflicting results. Therefore, the aim of this systematic review and meta-analysis was to combine evidence from previous studies on the association of serum potassium concentration with both short and long-term mortality as well as the occurrence of ventricular arrhythmias. Design Systematic review and meta-analysis. Methods A structured search of MEDLINE and EMBASE databases yielded 23 articles published between 1990 and January 2017 that met the inclusion criteria. Study selection, data extraction and quality assessment were carried out by three reviewers. Random effects models were used to pool estimates across the included studies and sensitivity analyses were performed when possible. Results Twelve studies were included in the meta-analysis. Both pooled results from six studies investigating short-term mortality and from five studies examining long-term mortality revealed significantly increased risks in patients with serum potassium concentrations of <3.5 mEq/L, 4.5–<5.0 mEq/L and ≥5.0 mEq/L after acute myocardial infarction. In addition, a serum potassium concentration of <3.5 mEq/L was significantly associated with the occurrence of ventricular arrhythmias. Conclusions Mortality, both short and long term, and the occurrence of ventricular arrhythmias in patients with acute myocardial infarction seem to be negatively associated with hypokalemic serum potassium concentration. There is evidence for adverse consequences of serum potassium concentrations of ≥4.5 mEq/L. Due to the heterogeneity among existing studies, further research is necessary to confirm the need to change clinical practice guidelines.
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Affiliation(s)
- Miriam Giovanna Colombo
- MONICA/KORA Myocardial Infarction Registry, Central Hospital of Augsburg, Germany
- Institute of Epidemiology II, Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Germany
| | - Inge Kirchberger
- MONICA/KORA Myocardial Infarction Registry, Central Hospital of Augsburg, Germany
- Institute of Epidemiology II, Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Germany
- Chair of Epidemiology, UNIKA-T, Ludwig-Maximilians-Universität München, Germany
- Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares (CIBERcv), Spain
| | - Ute Amann
- MONICA/KORA Myocardial Infarction Registry, Central Hospital of Augsburg, Germany
- Institute of Epidemiology II, Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Germany
- Chair of Epidemiology, UNIKA-T, Ludwig-Maximilians-Universität München, Germany
| | - Lisa Dinser
- MONICA/KORA Myocardial Infarction Registry, Central Hospital of Augsburg, Germany
- Institute of Epidemiology II, Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Germany
| | - Christa Meisinger
- MONICA/KORA Myocardial Infarction Registry, Central Hospital of Augsburg, Germany
- Institute of Epidemiology II, Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Germany
- Chair of Epidemiology, UNIKA-T, Ludwig-Maximilians-Universität München, Germany
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25
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Weinberg L, Harris L, Bellomo R, Ierino F, Story D, Eastwood G, Collins M, Churilov L, Mount P. Effects of intraoperative and early postoperative normal saline or Plasma-Lyte 148® on hyperkalaemia in deceased donor renal transplantation: a double-blind randomized trial. Br J Anaesth 2017; 119:606-615. [DOI: 10.1093/bja/aex163] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2017] [Indexed: 11/12/2022] Open
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Rafique Z, Kosiborod M, Clark CL, Singer AJ, Turner S, Miller J, Char D, Peacock WF. Study design of Real World Evidence for Treatment of Hyperkalemia in the Emergency Department (REVEAL-ED): a multicenter, prospective, observational study. Clin Exp Emerg Med 2017; 4:154-159. [PMID: 29026889 PMCID: PMC5635459 DOI: 10.15441/ceem.17.207] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 03/26/2017] [Accepted: 03/28/2017] [Indexed: 11/23/2022] Open
Abstract
Objective Hyperkalemia affects up to 10% of hospitalized patients and, if left untreated, can lead to serious cardiac arrhythmias or death. Although hyperkalemia is frequently encountered in the emergency department (ED), and is potentially life-threatening, standard of care for the treatment is poorly defined, with little supporting evidence. The main objectives of this observational study are to define the overall burden of hyperkalemia in the ED setting, describe its causes, the variability in treatment patterns and characterize the effectiveness and safety of ED standard of care therapies used in the United States. Methods This is an observational study evaluating the management of hyperkalemia in the ED. Two hundred and three patients who presented to the ED with a potassium value ≥5.5 mmol/L were enrolled in the study at 14 sites across the United States. Patients were treated per standard of care practices at the discretion of the patient’s physician. In patients who received a treatment for hyperkalemia, blood samples were drawn at pre-specified time points and serum potassium values were recorded. The change in potassium over 4 hours and the adverse events after standard of care treatment were analyzed. Results and Conclusion This article describes the background, rationale, study design, and methodology of the REVEAL-ED (Real World Evidence for Treatment of Hyperkalemia in the Emergency Department) trial, a multicenter, prospective, observational study evaluating contemporary management of patients admitted to the ED with hyperkalemia.
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Affiliation(s)
- Zubaid Rafique
- Ben Taub General Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, MO, USA
| | | | - Adam J Singer
- Stony Brook School of Medicine, Stony Brook, NY, USA
| | | | | | | | - W Frank Peacock
- Ben Taub General Hospital, Baylor College of Medicine, Houston, TX, USA
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27
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Abstract
Hyperkalemia is a potentially life-threatening electrolyte disorder appreciated with greater frequency in patients with renal disease, heart failure, and with use of certain medications such as renin angiotensin aldosterone inhibitors. The traditional views that hyperkalemia can be reliably diagnosed by electrocardiogram and that particular levels of hyperkalemia confer cardiotoxic risk have been challenged by several reports of patients with atypic presentations. Epidemiologic data demonstrate strong associations of morbidity and mortality in patients with hyperkalemia but these associations appear disconnected in certain patient populations and in differing clinical presentations. Physiologic adaptation, structural cardiac disease, medication use, and degree of concurrent illness might predispose certain patients presenting with hyperkalemia to a lower or higher threshold for toxicity. These factors are often overlooked; yet data suggest that the clinical context in which hyperkalemia develops is at least as important as the degree of hyperkalemia is in determining patient outcome. This review summarizes the clinical data linking hyperkalemia with poor outcomes and discusses how the efficacy of certain treatments might depend on the clinical presentation.
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Affiliation(s)
- John R Montford
- Division of Renal Disease and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; .,Renal Section, Medicine Service, Veterans Affairs Eastern Colorado Health System, Denver, Colorado; and
| | - Stuart Linas
- Division of Renal Disease and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado.,Division of Nephrology, Department of Medicine, Denver Health and Hospitals, Denver, Colorado
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28
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Singer AJ, Thode HC, Peacock WF. A retrospective study of emergency department potassium disturbances: severity, treatment, and outcomes. Clin Exp Emerg Med 2017; 4:73-79. [PMID: 28717776 PMCID: PMC5511959 DOI: 10.15441/ceem.16.194] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Revised: 12/21/2016] [Accepted: 12/22/2016] [Indexed: 01/18/2023] Open
Abstract
Objective Disturbances in potassium (K) levels are relatively common and may be associated with significant morbidity and mortality; however, treatments vary. Our purpose was to determine the incidence, treatments, and outcomes associated with hyperkalemia and hypokalemia in emergency department (ED) patients. Methods We performed a structured, retrospective review of electronic medical records of consecutive adult ED patients with K measured while in the ED. Demographic, clinical, and laboratory data as well as treatments, disposition, and in-hospital complications were collected. Univariate and multivariate analyses, presented as adjusted odds ratios, were used to compare outcomes by K levels. Results Of 100,260 visits in 2014, an ED K level was ordered in 48,827 (49%). A total of 1,738 patients (3.6%) were excluded because of sample hemolysis. The K was low (<3.5 mEq/L) in 5.5%, normal (3.5 to 5.0 mEq/L) in 90.9%, and elevated (>5.0 mEq/L) in 3.6% of patients. Patients with hyperkalemia were older (64 vs. 49 years, P<0.001) and more likely male (58% vs. 40%, P<0.001). Treatment for hyperkalemia varied greatly. After adjusting for confounders, both hyperkalemia and hypokalemia were associated with inpatient hospitalization and death. At least one medication was used to manage hyperkalemia in 11.5% of patients with a K of 5.1 to 5.4 mEq/L, 36.4% of those with a K 5.5 to 6 mEq/L and 77.0% of the cohort with K >6 mEq/L. Conclusion Hyperkalemia or hypokalemia occur in 1 of 11 ED patients and are associated with inpatient admission and mortality. Treatment of hyperkalemia varies greatly suggesting the need for evidence-based treatment guidelines.
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Affiliation(s)
- Adam J Singer
- Department of Emergency Medicine, Stony Brook University, Stony Brook, NY, USA
| | - Henry C Thode
- Department of Emergency Medicine, Stony Brook University, Stony Brook, NY, USA
| | - W Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
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29
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Serum potassium concentrations: Importance of normokalaemia. Med Clin (Barc) 2017; 148:562-565. [PMID: 28431898 DOI: 10.1016/j.medcli.2017.03.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 03/07/2017] [Accepted: 03/08/2017] [Indexed: 11/23/2022]
Abstract
Abnormalities in potassium concentrations are associated with morbidity and mortality. In recent years it has been considered that small variations in serum potassium concentrations within normal intervals may also be associated with mortality. Strategies for achieving normokalaemia include dietary measures, limiting the use of potassium retaining drugs, and use of conventional cation exchange resins (calcium/sodium polystyrene sulfonate) and/or the new non-absorbed cation exchange polymer (patiromer).
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